American College of Radiology
ACR Appropriateness Criteria®

Chronic Knee Pain

Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography knee Usually appropriate Moderate 1 ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 16
References Study Quality
10 (24751528) 4
11 (26797169) 4
12 (23118113) 2
13 (22438445) 3
CT arthrography knee Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT knee with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT knee without IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 1 1 2 0 1 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
Aspiration knee Usually not appropriate Expert Consensus 1 Varies Varies 1 1 14 0 1 1 0 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 1 0 0 0 0
MRI knee without IV contrast Usually not appropriate Limited 3 O 0 mSv O 0 mSv [ped] 1 1 11 0 2 2 0 0 0 1 0
References Study Quality
2 (25086957) 4
MRI knee without and with IV contrast Usually not appropriate Limited 3 O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 0 0 1 0 0
References Study Quality
2 (25086957) 4
Tc-99m bone scan knee Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv 1 1 13 2 1 0 0 0 0 0 0
US knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 1 1 2 0 1 0 0
Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 4 10
References Study Quality
11 (26797169) 4
13 (22438445) 3
15 (25442030) 4
17 (21647860) 2
18 (23321609) 4
19 (22736267) 2
20 (22012846) 4
21 (18784100) 4
22 (25022807) 2
23 (24020939) 2
24 (23377800) 2
25 (20829200) 4
26 (21360498) 2
27 (26290325) 3
28 (28473086) 4
29 (23845401) 3
30 (24583066) 2
31 (25724258) 3
32 (22421281) 2
33 (21969432) 4
34 (24651059) 4
35 (23982988) 2
36 (22184170) 4
37 (20418103) 4
38 (24119160) 2
39 (21618936) 4
40 (22862803) 4
41 (23478924) 4
42 (20884045) 4
43 (22488011) 4
44 (22134205) 4
45 (26242763) 2
CT arthrography knee May be appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 0 3 5 5 1 1 0
References Study Quality
16 (22447237) 4
CT knee without IV contrast May be appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 0 1 11 4 0 0 0
References Study Quality
15 (25442030) 4
Aspiration knee May be appropriate Limited 3 Varies Varies 5 5 1 0 0 1 12 3 0 0 0
References Study Quality
10 (24751528) 4
US knee May be appropriate (Disagreement) Expert Opinion 2 O 0 mSv O 0 mSv [ped] 5 5 1 1 1 1 8 2 2 1 0
References Study Quality
10 (24751528) 4
17 (21647860) 2
37 (20418103) 4
44 (22134205) 4
49 (22996306) 2
Radiography hip ipsilateral May be appropriate Limited 3 ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 2 1 0 2 10 1 1 0 0
References Study Quality
14 (23781753) 4
Radiography lumbar spine May be appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 3 1 0 1 11 0 1 0 0
MR arthrography knee May be appropriate Limited 3 O 0 mSv O 0 mSv [ped] 4 4 6 0 2 6 3 0 0 0 0
References Study Quality
10 (24751528) 4
MRI knee without and with IV contrast Usually not appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 2 2 8 1 1 2 2 1 1 0 0
References Study Quality
15 (25442030) 4
17 (21647860) 2
42 (20884045) 4
46 (23277189) 2
47 (21187293) 2
48 (25278070) 2
CT knee with IV contrast Usually not appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 1 0 0 0 0
References Study Quality
15 (25442030) 4
CT knee without and with IV contrast Usually not appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 0 2 1 0 0 0 0
References Study Quality
15 (25442030) 4
Tc-99m bone scan knee Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv 1 1 12 3 0 0 1 0 0 0 0
Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 1 12
References Study Quality
41 (23478924) 4
50 (18552309) 3
51 (24856089) 2
52 (21327672) 2
53 (24685525) 2
54 (24048551) 1
CT arthrography knee May be appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 6 6 1 0 0 1 4 3 5 2 0
References Study Quality
16 (22447237) 4
CT knee without IV contrast May be appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 1 11 4 0 0 0
MR arthrography knee May be appropriate (Disagreement) Expert Opinion 2 O 0 mSv O 0 mSv [ped] 5 5 3 0 0 2 7 4 1 0 0
References Study Quality
10 (24751528) 4
16 (22447237) 4
US knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 2 2 7 8 0 0 1 1 0 0 0
CT knee with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 3 0 2 0 0 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 1 1 0 0 0 0 0
Aspiration knee Usually not appropriate Expert Consensus 1 Varies Varies 1 1 13 1 0 2 0 0 0 0 0
MRI knee without and with IV contrast Usually not appropriate Limited 3 O 0 mSv O 0 mSv [ped] 1 1 11 2 0 1 1 1 0 0 0
References Study Quality
16 (22447237) 4
Tc-99m bone scan knee Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv 1 1 14 2 0 0 0 0 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 1 1 0 0 0 0 0
Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates degenerative changes or chondrocalcinosis. Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast May be appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 1 6 2 3 2
References Study Quality
10 (24751528) 4
11 (26797169) 4
18 (23321609) 4
19 (22736267) 2
55 (26316262) 3
56 (24418678) 2
57 (25746322) 2
58 (20360517) 3
59 (24821663) 3
Aspiration knee May be appropriate (Disagreement) Expert Opinion 2 Varies Varies 5 5 3 1 0 2 7 4 0 0 0
References Study Quality
61 (26116548) 2
CT knee without IV contrast May be appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 5 1 2 1 7 1 0 0 0
MRI knee without and with IV contrast Usually not appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 2 2 8 1 1 2 2 1 1 0 0
References Study Quality
10 (24751528) 4
11 (26797169) 4
18 (23321609) 4
19 (22736267) 2
55 (26316262) 3
56 (24418678) 2
57 (25746322) 2
58 (20360517) 3
59 (24821663) 3
US knee Usually not appropriate Limited 1 O 0 mSv O 0 mSv [ped] 2 2 7 2 0 3 5 0 0 0 0
References Study Quality
11 (26797169) 4
60 (25691769) 1
CT arthrography knee Usually not appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 0 3 3 0 1 0 0
References Study Quality
11 (26797169) 4
CT knee with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 2 1 0 0 0 0 0
CT knee without and with IV contrast Usually not appropriate Expert Consensus 1 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 1 2 0 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 1 1 0 0 0
Tc-99m bone scan knee Usually not appropriate Limited 3 ☢☢☢ 1-10 mSv 1 1 10 2 2 1 1 0 0 0 0
References Study Quality
11 (26797169) 4
Radiography hip ipsilateral Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
Variant 5: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates signs of prior osseous injury (ie, Segond fracture, tibial spine avulsion, etc.). Next imaging procedure.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI knee without IV contrast Usually appropriate Limited 1 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 2 2 3 9
References Study Quality
41 (23478924) 4
65 (20978758) 2
CT arthrography knee May be appropriate Strong 3 07 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 7 5 2 1 0
References Study Quality
16 (22447237) 4
62 (18329214) 2
63 (11997545) 2
64 (10966722) 2
CT knee without IV contrast May be appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 13 2 0 0 0
References Study Quality
15 (25442030) 4
CT knee with IV contrast Usually not appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 0 1 0 0 0
References Study Quality
15 (25442030) 4
CT knee without and with IV contrast Usually not appropriate Limited 3 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 1 0 1 0 1 0 0 0
References Study Quality
15 (25442030) 4
Aspiration knee Usually not appropriate Expert Consensus 1 Varies Varies 1 1 14 0 1 1 0 0 0 0 0
MR arthrography knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 1 1 11 1 1 1 0 1 1 0 0
MRI knee without and with IV contrast Usually not appropriate Limited 1 O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 0 0 0 0
References Study Quality
41 (23478924) 4
65 (20978758) 2
Tc-99m bone scan knee Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 1 0 0 0
US knee Usually not appropriate Expert Consensus 1 O 0 mSv O 0 mSv [ped] 1 1 12 2 1 1 0 0 0 0 0
Radiography hip ipsilateral Usually not appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 0 0 1 0 0 1 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.